Case Report West Nile Virus Infection in Pregnancydownloads.hindawi.com/journals/criid/2013/351872.pdf · 2019. 7. 31. · any obvious signs of infection and without leukocytosis.

Hindawi Publishing CorporationCase Reports in Infectious DiseasesVolume 2013, Article ID 351872, 3 pageshttp://dx.doi.org/10.1155/2013/351872

Case ReportWest Nile Virus Infection in Pregnancy

Robert D. Stewart, Stefanie N. Bryant, and Jeanne S. Sheffield

Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center,5323 Harry Hines Bolevard, Dallas, TX 75390-9032, USA

Correspondence should be addressed to Robert D. Stewart; [email protected]

Received 10 January 2013; Accepted 14 February 2013

Academic Editors: J. Koirala and S. Yazar

Copyright © 2013 Robert D. Stewart et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

A recent outbreak of West Nile virus has allowed for observations as to the clinical course of this emerging pathogen duringpregnancy. We present three cases of West Nile virus infection during pregnancy. Case 1 presented at term with focal subjectiveweakness and fever.With supportive care, her symptoms were resolved within 7 days, and she subsequently delivered an unaffectedterm infant. Case 2 presented in the first trimester with fever and headache. Her symptoms were resolved in 8 days with supportivecare. Case 3 was diagnosed during the first trimester during workup of nonspecific respiratory symptoms, with resolution of allsymptoms in 24 days. Obstetricians need to be aware of the varied clinical presentation of West Nile virus during pregnancy.

1. Background

Since it was first detected in New York in 1999 [1], WestNile virus (WNV) has become an increasingly importantpathogen in the United States. Most cases of WNV areasymptomatic; however, infection can result in febrile illness,encephalitis, meningitis, or poliomyelitis. The first case ofintrauterine-acquired WNV was reported in 2002 [2], andin 2003 a case of maternal WNV encephalitis was reported[3]. In the summer of 2012, the United States experienced anepidemic of WNV, with 5,245 cases and 236 deaths reportedto the Centers for Disease Control and Prevention. Texashas reported 1714 cases with 76 deaths thus far, with DallasCounty being the most severely affected. According to theTexas Department of State Health Services, 400 cases ofWNV illness and 18 WNV deaths have occurred in DallasCounty to date. Here we report our experience with 3 casesof maternal WNV illness during pregnancy at ParklandHospital.

2. Case 1

A 41-year-old G6P4A1 Hispanic female at 37-week gestationwas presented to Labor andDelivery complaining of two daysof bilateral lower extremity weakness with difficulty walking,fevers, and chills. She denied headaches, nuchal rigidity,

nausea, vomiting, other weakness, or loss of sensation. Herprenatal care was complicated by diet controlled gestationaldiabetes. On arrival, she was febrile to 38.2∘C with a pulse of120. Her initial physical examination was otherwise benignwith a normal neurological examination without any focaldeficits. Strength was normal (5/5) in all extremities. Fetalheart tones were reassuring. Initial labs were negative forany obvious signs of infection and without leukocytosis.West Nile virus antibodies were drawn on admission. Shebecame afebrile with acetaminophen and was admitted to theantepartum unit for further observation. On hospital day 1,she again complained of weakness and difficulty walking andwas febrile to 39.0∘C. Neurological examination remainedunchanged, but, in light of continuedneurological complaintswith febrile episodes, the neurology service was consulted.Neurology confirmed a benign nonfocal neurological examand agreed with infectious workup in progress. Later thatnight, she again was febrile to 38.3∘Cwith a new complaint ofseveral episodes of watery diarrhea. StoolWBC,O&P, cultureand Clostridium difficile studies were sent. The next day shereported improvement in her subjective weakness; however,she was febrile to 38.6∘C. Because of unclear etiology andepisodic fevers, she was observed on Labor andDelivery withfetal monitoring for several hours that remained reassuring.She remained afebrile for the remainder of her hospital staywith continual improvement in symptoms. Her stool, urine

2 Case Reports in Infectious Diseases

and blood cultures were all negative. Her West Nile virusimmunoglobulin (Ig)M resulted positive with negative IgG.Shewas discharged homeonhospital day 5 after being afebrilewith resolution of her lower extremity weakness. She did notkeep her follow-up appointment in clinic.

At 38 weeks she presented to Labor and Delivery inactive labor. She had an uncomplicated vaginal delivery of2720 gm male infant, Apgar 8/9. On readmission her WestNile IgG was positive and IgM negative. Fetal cord bloodwas West Nile IgG positive and IgM negative. Infant serumon day of life 2 was WNV IgG positive and IgM negative.The infant’s course was complicated by transientmild tachyp-nea that resolved on day of life 1 with no interventions.Maternal postpartum course was complicated by elevatedblood pressures which required several doses of apresolineand initiation of amlodipine 10mg daily on discharge. Sincedelivery, the infant has done well with no apparent postnataleffects. The patient was doing well at her postpartum visitwith no apparent complications.

3. Case 2

A 29-year-old G4P3 Hispanic female at 10-week gestationwas presented to the emergency department complaining of4 days of fever and frontal-occipital headache with upperback myalgias. She had associated nausea but no vomiting.On presentation, she was febrile at 38.4∘C and tachycardicat 110 bpm. On examination she had no neurological find-ings, her chest was clear, and her cardiac exam revealedtachycardia with normal rhythm. Her laboratory testing wasnormal. Respiratory DFA, influenza testing, and chest X-ray were normal. West Nile virus antibodies were obtainedon admission. She was admitted for supportive care for apresumed upper respiratory infection. Her headache andfevers were treated with acetaminophen and she was givenintravenous hydration. She was not initiated on antibiotics.On hospital day 1 her temperature rose to 39.1∘C; however,her therapy was not changed and a repeat chest X-ray atthis time showed no changes from admission. She remainedintermittently febrile on hospital day 2, but had no newexam findings and reported subjective improvement of hersymptoms, with resolution of her headache. By hospital day4 she had remained afebrile for over 24 hours and had fullimprovement in her symptoms. She was discharged homewith followup in our clinic. Nine days after discharge, herWest Nile IgM and IgG both returned positive. She wasfollowed up in our clinic sixteen days after discharge andreported full resolution of her symptoms. She is currently 14-week pregnant and without further complications.

4. Case 3

A 33-year-old G4P3 Hispanic female was presented to theemergency department at 12-week gestation, complaining of2 days of difficulty breathing and a nonproductive cough,with associated subjective fever and chills, and one episode ofemesis. She had nomedical history and her prior pregnancieswere uncomplicated. While in the emergency department,

she was afebrile and mildly tachycardic at 100 bpm. Bothcardiac and neurological examinations were normal; how-ever, bilateral expiratory wheezing was present. Influenzatesting, respiratory DFA, Tuberculosis immunoglobulin,throat culture, and chest X-ray were all negative for anyabnormality. The remainder of her laboratory testing wasnormal. She was monitored in the emergency departmentwhere she received hydration and one albuterol nebulizertreatment with improvement in her symptoms. She remainedafebrile with symptomatic improvement. A prescription foran albuterol inhaler was given, and she was discharged homewith a suspected viral syndrome and associated reactiveairway disease. At the time of discharge West Nile IgM andIgG were pending. Seven days after discharge her West NileIgM and IgG both returned positive, and she was calledto our clinic. At that time she complained of continueddyspnea, improved since her prior visit. She had no othersymptoms and was afebrile with a normal exam, includingno further wheezing. She was admitted for observation andsymptomatic care with albuterol of which she received onetreatment. On hospital day 1 her symptoms had resolvedand she was discharged home. She was again seen in ourclinic 7 days after discharge with a mild cough, for whichshe continued her albuterol inhaler as needed. She wasafebrile with normal vital signs and an unremarkable exam.She returned seven days later, at which time she had fullresolution of her symptoms. A sonogram was performedat 17-week gestation, showing a singleton fetus without anyanomalies. She is currently at an estimated gestational age of19 weeks and without further complications.

5. Comment

WNV is a single-stranded mosquito-borne RNA flavivirusthat is transmitted to humans through the bite of aninfected mosquito. Approximately 80% of people with WNVremain asymptomatic. Of the 20% who develop symptoms,most develop West Nile fever, which consists of a febrileillness with an incubation period of 2–14 days. Clinicalfindings that accompany the fever are usually nonspecific andinclude malaise, anorexia, nausea, vomiting, myalgia, rash,and lymphadenopathy. Less than 1% of infected individualsdevelop WNV neuroinvasive disease, which can present asan aseptic meningitis or encephalitis. Clinical features ofsevere disease include fever, ataxia, optic neuritis, seizures,weakness, altered mental status, and myelitis. Risk factorsfor the development of severe disease include older age andimmunosuppression. Diagnostic testing of WNV involvesdemonstrating West Nile specific IgM antibody in the serumof the infected individual. If West Nile IgM is present in thecerebrospinal fluid of an infected individual, it is diagnosticof WNV meningoencephalitis. There is no specific antiviraltreatment of WNV, and care is generally supportive.

The obvious concern with WNV infection during preg-nancy is the possibility of teratogenicity or adverse pregnancyoutcomes. While intrauterine infection has been reported,with delivery of a fetus with bilateral chorioretinitis and

Case Reports in Infectious Diseases 3

Table 1: Selected characteristics of West Nile virus infection duringpregnancy at a single institution.

Case 1 Case 2 Case 3Maternal age (years) 41 29 33Gestational age at presentation (weeks) 37 10 12Fever Yes Yes NoHeadache No Yes NoNausea/vomiting No Yes YesNeurologic symptoms Yes No NoDuration of hospitalization (days) 5 4 1Duration of symptoms (days) 7 8 24

cerebral abnormalities [2], a review of birth outcomes fol-lowing maternal WNV infection in a national cohort didnot demonstrate a significantly increased rate of adverseinfant outcomes, including birth defects [4]. The rate ofspontaneous abortion, preterm delivery, and low birth weightwas no higher in the cohort of infected women comparedto the general population. Of the 72 infants born of thesewomen, only 3 possibly hadWNV that could have been con-genitally acquired although none had conclusive laboratoryevidence [4]. Similarly, the study by Paisley et al. did notdemonstrate any significant differences in infants of WNVseronegative versus seropositive women. They also foundthat the seroprevalence of WNV antibodies following anoutbreak of WNV was 4%, with no infants having detectableWNV specific IgM antibodies [5]. However, given the limitedreports of WNV infection complicating pregnancy, it isuncertain if WNV may have adverse effects on pregnancyoutcomes. Therefore, more study is needed to determine theclinical effects of WNV on pregnancy outcomes.

There is also limited evidence as to the effect that preg-nancy has on the clinical course of WNV infection. Whilemouse models have demonstrated that pregnancy increasesthe risk of severe WNV infection [6], limited evidence inhuman cases is available. The majority of currently availableevidence is limited to case reports [2, 3], which are likelyhampered by publication bias. A previous report of WNVencephalitis during pregnancy has been published, with apatient who became progressively obtunded and unrespon-sive after presenting febrile with meningeal signs. Withsupportive care she became responsive, but demonstratedresidual lower extremity weakness [3]. A study of serologicevidence of WNV disease found that 32% of the seropositivewomen had a fever during their pregnancy, and 27% ofseropositive women reported being told by a physician thatthey had WNV fever during their pregnancy. They did notreport any WNV neuroinvasive disease in the report [5].

As there is little evidence describing the natural history ofWNV in pregnancy, we offer our experience to help furtherdescribe the presentation ofWNV during pregnancy. Duringthe WNV season, we had a policy of aggressive screeningfor any pregnant woman who presented with neurologicsymptoms or febrile illness. Table 1 shows selected character-istics of our cases of WNV infection during pregnancy. Onlyone of our patients presented with neurologic symptoms.

The other two presented with a nonspecific illness, of whichone was febrile. We recognize the possibility that case 3 maybe an asymptomatic case ofWNV that was incidentally foundduring the workup of a nonrelated illness. The duration ofsymptoms in our experience was 7–24 days. There was noresidual neurologic sequelae in our series. The one infantborn as of publication had no evidence of intrauterineinfection. All three cases occurred remote from delivery,potentially decreasing the possibility of transmission to thefetus.

WNV is an epidemic infection in the United States, andwhile pregnancy does not appear to predispose to moreserious infection, this issue is in no way resolved. Regardlessof this, the potential consequences of WNV infection aresignificant and warrant aggressive screening of pregnantwomen who present with symptoms of infection, febrileillness, or neurological findings of unknown origin.The effectof pregnancy on WNV infection and the effect of maternalWNV infection on the fetus both require further investiga-tion. As treatment is supportive, the best action is to preventdisease acquisition, by recommending pregnant women towear protective clothing and use mosquito repellants.

References

[1] D. Nash, F. Mostashari, A. Fine et al., “The outbreak of WestNile virus infection in the New York City area in 1999,” TheNewEngland Journal ofMedicine, vol. 344, no. 24, pp. 1807–1814,2001.

[2] Q. Nguyen, C. Morrow, L. Novick et al., “Intrauterine WestNile virus infection - New York, 2002,”Morbidity and MortalityWeekly Report, vol. 51, no. 50, pp. 1135–1136, 2002.

[3] J. B. Chapa, J. T. Ahn, L. M. DiGiovanni, and M. A. Ismail,“West Nile virus encephalitis during pregnancy,” Obstetrics andGynecology, vol. 102, no. 2, pp. 229–231, 2003.

[4] D. R. O’Leary, S. Kuhn, K. L. Kniss et al., “Birth outcomesfollowing west nile virus infection of pregnant women in theUnited States: 2003-2004,” Pediatrics, vol. 117, no. 3, pp. e537–e545, 2006.

[5] J. E. Paisley, A. F. Hinckley, D. R. O’Leary et al., “West Nilevirus infection among pregnant women in a northern Coloradocommunity, 2003 to 2004,” Pediatrics, vol. 117, no. 3, pp. 814–820,2006.

[6] L. Cordoba, E. Escribano-Romero, A. Garmendia, and J. C. Saiz,“Pregnancy increases the risk of mortality in Wet Nile virus-infected mice,” Journal of General Virology, vol. 88, no. 2, pp.476–480, 2007.

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Case Report West Nile Virus Infection in Pregnancydownloads.hindawi.com/journals/criid/2013/351872.pdf · 2019. 7. 31. · any obvious signs of infection and without leukocytosis.

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